Capacity and consent: Knowledge and practice of legal and healthcare standards

Consent practices in midwifery: A survey of UK midwives

OBJECTIVE

To explore midwives' knowledge and understanding of the law and practice of consent in the post-Montgomery world.

DESIGN

Cross-sectional online survey. Descriptive statistical analysis of midwives' survey responses.

SETTINGS

Social media: Instagram, Facebook and Twitter. Survey distribution was via the UCL Opinio survey platform.

PARTICIPANTS

A total of 402 midwives, surveyed over a four month period between 2nd March and 2nd July 2021.

MEASUREMENTS

Knowledge of legal consent, 'sureness' of meeting current legal requirements and competence to gain consent.

FINDINGS

91% of participants acknowledged correctly that consent must be voluntary. 91% reported that women must be informed of all the risks associated with their care, although 26% reported that women should be informed of some of the risks associated with their care. Most participants were 'sure' that their discussions of consent meet current legal requirements (91%). 21% rated their competence to gain consent as 'excellent', 71% rated themselves as 'very good', whilst 1% rated their competence as 'poor'. Deficiencies in fundamental knowledge of consent were noted in some participants rating themselves highest in 'sureness' of meeting legal requirements and competence to consent.

KEY CONCLUSIONS

Fundamental gaps in midwives' knowledge of legal consent were identified. Participants demonstrated uncertainty regarding the extent of risk disclosure and discussion of alternative care options. Participants generally rated themselves highly in their consenting practices, despite lacking in basic knowledge of legal consent, revealing a discrepancy between midwives' self-perceptions and their actual knowledge.

IMPLICATIONS FOR PRACTICE

The overconfidence displayed by some participants is concerning for clinical midwifery practice. Professional education and guidance for midwives on legal consent in keeping with Montgomery is urgently required to ensure that midwives are legally compliant in their consenting practices.

Core competencies of healthcare professionals in Oman: Research and evidence-based practice needs attention

AIM

The aim of the study was to examine (1) the perceptions on core competencies of healthcare professionals working at clinical settings in Oman and (2) which demographic characteristics explain the overall core competency.

DESIGN

A cross-sectional design.

METHODS

Healthcare Professional Core Competency Instrument, consisting of 11 sub-scales with 81 items, was distributed to healthcare professionals (n = 1,543; 826 nurses and 717 physicians) who worked at primary, secondary and tertiary healthcare institutions. Descriptive statistics, t-test, ANOVA and linear regression were used for data analysis.

RESULTS

Altogether 1,078 healthcare professionals (628 nurses and 450 physicians) responded representing 70% overall response rate. Healthcare professionals perceived their overall core competence as excellent, safety being the highest, and research and evidence-based practice was the lowest. The multiple linear regression analysis revealed that ethnicity, gender and years of working experience were the characters that explained the overall core competence, where expatriate senior professionals reported higher competency levels compared with counterparts.

A novel curriculum for the Same-Sex Marriage Act and Patient Right to Autonomy Act (SMPRA) module based on two new laws in Taiwan: a mixed-methods study

BACKGROUND

The establishment of laws has had a tremendous impact on holistic medical care. The Patient Right to Autonomy (PRA) Act and the Same-Sex Marriage Act have been passed in Taiwan, and both have sparked intense societal debate. The Same-Sex Marriage Act and PRA Act (SMPRA) teaching module was created for the Gender, Medicine, and Law (GML) course of the medical curriculum. This video trigger-assisted problem-based learning (VTA-PBL) software has integrated content on the aforementioned legislative proclamations. It upends conventional beliefs and fosters reflective practices on sexual rights and the right to representation among medical students. This study examined how the SMPRA module affected the knowledge and attitudes of medical students taking up the GML course.

METHODS

A simple pre-/post-test design evaluated the outcomes of the PBL module to examine the changes in knowledge and attitudes of medical students toward same-sex marriage rights. In 2019 and 2020, 126 and 49 5th-year medical students took up the GML course, respectively. The GML components included a video scenario representing advanced decision-making and a healthcare agency with a same-sex couple, a PBL discussion, and student feedback presentations. The mechanisms of feedback collection and measuring student knowledge and attitudes toward sexual rights differed between one cohort in 2019 and the other in 2020. Pre- and post-lecture tests were used in the first school year, whereas a post-lecture open-ended questionnaire survey was used in the second school year.

RESULTS

In total, 90 and 39 eligible questionnaires were received in the first and second school years, respectively, which corresponded to response rates of 71% and 80%. Students showed a better understanding of and positive enhancement of proficiency in legal and ethical content and relevant clinical practice. Qualitative analysis revealed that students viewed healthcare providers as checkpoints for conflicts of interest; medical ethics as the cornerstone of clinical practice; cultural background as a significant influence on decision-making; and empathetic communication as the cornerstone of relationships between patients, family members, and doctors.

CONCLUSION

The GML course of the SMPRA module fosters reflective practices on ethical and legal sexual rights issues.

Decision-Making Capacity to Refuse Treatment at the End of Life: The Need for Recognizing Real-World Practices

End-of-life decision making is a troublesome ethical dilemma. These decisions should be made in trustful patient–doctor relationships. We aimed to propose a balanced approach when discussing this complex issue. We categorized the research into four approaches and suggest that a multidisciplinary approach may be appropriate. We also analyzed the pitfalls of the multidisciplinary approach. Our conclusion is two-fold. First, discussions in this field should be based on real-world practice. If this is not the case, the proposal may be armchair theory, which is not effective in a clinical setting. Second, interdisciplinary researchers should not stick to their position too firmly and should listen to others. Otherwise, proposals made will be paternalistic or philosophically biased. Therefore, when philosophical collaboration is applied to the topic of clinical bioethics, it is necessary to thoroughly examine different positions and carry out careful discussions with consideration for medical care settings. Researchers must also understand what is needed for a trustful patient–doctor relationship. By making such efforts, clinical bioethics will contribute to the wellbeing of patients.

Assessment of older adults' decision-making capacity in relation to independent living: A scoping review

With a growing global ageing population, approaches to assess and support decision-making are becoming more pertinent. This scoping review aimed to identify and map current knowledge on assessment of older adults' decision-making capacity in relation to independent living. A five-stage scoping review framework was followed. Inclusion criteria were papers on assessment approaches used to evaluate decision-making capacity of older adults, aged 60 years and over for independent living, including studies involving people with cognitive impairment and dementia. Five databases were searched for publications with eligibility criteria from January 2000 to December 2020; 4,118 results were retrieved from sources, resulting in 29 publications being analysed, eight of which were research reports. Publication characteristics and methodologies varied; however, many common components of decision-making capacity assessment for independent living were identified including cognitive, functional, environmental and risk assessment. Overall, a multidisciplinary approach was recommended, and consideration of the person's values and preferences is noted in many publications. Decision-making capacity assessment for independent living of older adults requires multicomponent, multidisciplinary assessment. Future work is needed to examine this from the perspective of older adults and their caregivers.

Assessing Older Adults’ Decision-Making Capacity for Independent Living: Practice Tensions and Complexities

Decision-making capacity (DMC) is a salient issue due to increasing ageing populations and associated dementia-related diseases. Legislative and policy developments emphasise older adults’ rights to participate in decision-making. Fifty-two occupational therapists working with older adults from a range of practice settings in Ireland participated in focus groups to discuss their contribution to multidisciplinary assessments of older adult’s DMC for independent living. Findings indicate lack of shared understanding of DMC and conflicting philosophies of practice and highlight the need for a comprehensive and multidisciplinary approach. Findings also highlight that older people are often excluded from care-planning, and independent living options are determined by availability of community services rather than their preferences. Future research will attempt to inform practice in assessing and supporting older adults’ DMC for independent living.

Algorithm for the use of the Guardianship Act, the Mental Health Act and the Public Health Act in emergency departments in New South Wales

OBJECTIVE

To address frequently asked questions regarding the use of the Guardianship Act, the Mental Health Act and the Public Health Act within New South Wales EDs and present an algorithm to guide the use of this legislation.

METHODS

An ED-specific algorithm was developed for the use of the three pieces of legislation. Then an emergency psychiatrist and an emergency physician reviewed the algorithm with ED staff to understand its usefulness and where further detail was required. Frequently asked questions were collated.

RESULTS

Frequently asked questions are addressed with reference to the algorithm.

CONCLUSION

This paper offers an algorithm that can be easily followed for use in EDs across New South Wales.

Navigating the Minefield: Managing Refusal of Medical Care in Older Adults with Chronic Symptoms of Mental Illness

Purpose

The purpose of this case series is to illustrate the complexity of considerations across health (physical and mental), ethical, human rights and practical domains when an older adult with chronic symptoms of mental illness refuses treatment for a serious medical comorbidity. A broad understanding of these considerations may assist health care professionals in navigating this challenging but common aspect of clinical practice.

Case Presentation

Three detailed case reports are described. Participants were older adults with an acute presentation of a chronic mental illness, admitted to a specialized older persons mental health inpatient unit (OPMHU) in an Australian metropolitan hospital. Significant comorbid medical issues were detected or arose during the admission and the patient refused the recommended medical intervention. Data extracted from patients' medical records were analyzed and synthesized into detailed case reports using descriptive techniques. Each patient was assessed as lacking capacity for healthcare and treatment consent and did not have relatives or friends to assist with supported decision-making. Multifaceted aspects of decision-making and management are highlighted.

Conclusion

There are multiple complex issues to consider when an older adult with chronic symptoms of mental illness refuses treatment for serious comorbid medical conditions. In addition to optimizing management of the underlying mental illness (which may be impairing capacity to make healthcare decisions), clinicians should adopt a role of advocacy for their patients in considering the potential impact of ageism and stigma on management plans and inequities in physical healthcare. Consultation with specialist medical teams should incorporate multifaceted considerations such as potentially inappropriate treatment and optimum setting of care. Equally important is reflective practice; considering whether treatment decisions may infringe upon human rights or cause trauma.

Adequacy of measures of informed consent in medical practice: A systematic review

As a critical component of medical practice, it is alarming that patient informed consent does not always reflect (1) adequate information provision, (2) comprehension of provided information, and (3) a voluntary decision. Consequences of poor informed consent include low patient satisfaction, compromised treatment adherence, and litigation against medical practitioners. To ensure a well-informed, well-comprehended, and voluntary consent process, the objective and replicable measurement of these domains via psychometrically sound self-report measures is critical. This systematic review aimed to evaluate the adequacy of existing measures in terms of the extent to which they assess the three domains of informed consent, are psychometrically sound and acceptable for use by patients. Extensive searching of multiple databases (PsychINFO, PubMed, Sociological Abstracts, CINAHL, AMED) yielded 10,000 potential studies, with 16 relevant scales identified. No existing scale was found to measure all three consent domains, with most only narrowly assessing aspects of any one domain. Information provision was the most frequently assessed domain, followed by comprehension, and then voluntariness. None of the identified scales were found to have adequate evidence for either high quality psychometric properties or patient user acceptability. No existing scale is fit for purpose in comprehensively assessing all domains of informed consent. In the absence of any existing measure meeting the necessary criteria relating to information, comprehension and voluntariness, there is an urgent need for a new measure of medical consent to be developed that is psychometrically sound, spans all three domains and is acceptable to patients and clinicians alike. These findings provide the impetus and justification for the redesign of the informed consent process, with the aim to provide a robust, reliable and replicable process that will in turn improve the quality of the patient experience and care provided.

Making clinical care decisions with people living with dementia in hospital: An integrative literature review

BACKGROUND

As our population ages, the percentage of hospitalised patients diagnosed with dementia is expected to rise. However, there is emerging evidence that people living with dementia may experience discrimination and exclusion from decisions about their clinical care. Although dementia affects cognition, many patients living with dementia want to participate in decision-making processes relating to their clinical care in hospital.

OBJECTIVE

Identify the processes associated with making decisions about clinical care with people living with dementia in hospital.

DESIGN

An integrative literature review.

DATA SOURCES

Cumulative Index of Nursing and Allied Health Literature (CINAHL), Scopus, EMBASE (Ovid), MEDLINE (PubMED), PsycINFO and HeinOnline.

REVIEW METHOD

One author conducted the initial screening of titles, and two authors screened in subsequent rounds for abstracts and full text. The process of making clinical decisions was the outcome of interest. Articles about people with cognitive impairment that did not include dementia, or decisions such as discharge planning or end of life care were excluded. An inductive synthesis of the findings was undertaken.

RESULTS

Nine articles were identified for review and included expert opinion or hypothetical discussion (n=5), cross-sectional survey research (n=3), and qualitative research (n=1). Three themes were identified: capacity for decision-making is conceptualised as 'all or nothing'; there are no universal principles for including people living with dementia in decision-making in acute care settings; and autonomy is recognised but superseded by beneficence.

CONCLUSIONS

Contemporary hospital practice is focused on determining capacity for decisions, with an all or nothing attitude to capacity, effectively excluding many people living with dementia from participation in decisions. While there is limited evidence to guide clinicians in this complex and situated process of making clinical decisions, emerging models of supported decision-making require further evaluation in the hospital setting.

Influence of Core Competence on Voice Behavior of Clinical Nurses: A Multicenter Cross-Sectional Study

Background

Voice behavior, referred to as a positive guarantee for organizational development, is influenced by several kinds of individual, collective and organizational features. However, the impact of individual competence on voice behavior is unclear. The aim of the present study was to investigate the status quo of core competence and voice behavior of clinical nurses and explore the impact of core competence on nurses’ voice behavior.

Methods

A multicenter cross-sectional survey. A total of 1717 nurses were recruited from nine tertiary and secondary hospitals between March and June 2019. An online questionnaire, including socio-demographic variables, employee voice behavior scale and competence inventory for registered nurses, was used to investigate prohibitive and promotive voice behavior and core competence of clinical nurses. Pearson correlation and hierarchical multiple regression were performed in the data analysis.

Results

The mean score for prohibitive and promotive voice behavior of nurses were 3.46 (SD 0.77) and 3.46 (SD 0.88), respectively. The mean score for core competence was 2.46 (SD 0.77). Critical thinking/research aptitude was the most important predictor for both prohibitive and promotive voice behavior (each p < 0.05), but its influence on promotive voice behavior was greater (p < 0.05). Leadership was another significant predictor for prohibitive voice behavior (p < 0.05). Legal/ethical practice, teaching-coaching, professional development and shift work were other predictors for promotive voice behavior (each p < 0.05).

Conclusion

Clinical nurses experience modest levels of prohibitive and promotive voice behavior and their core competence is moderate. Core competence, especially critical thinking/research aptitude, impacts significantly on voice behavior of clinical nurses. Cultivating nurses’ core competence could positively increase their voice behavior for organizational development.

Mental Capacity Assessments for COVID-19 Patients: Emergency Admissions and the CARD Approach

The doctrine of consent (or informed consent, as it is called in North America) is built upon presumptions of mental capacity. Those presumptions must be tested according to legal rules that may be difficult to apply to COVID-19 patients during emergency presentations. We examine the principles of mental capacity and make recommendations on how to assess the capacity of COVID-19 patients to consent to emergency medical treatment. We term this the CARD approach (Comprehend, Appreciate, Reason, and Decide).

Understanding Ethical and Legal Obligations in a Pandemic: A Taxonomy of "Duty" for Health Practitioners

From the ethics perspective, "duty of care" is a difficult and contested term, fraught with misconceptions and apparent misappropriations. However, it is a term that clinicians use frequently as they navigate COVID-19, somehow core to their understanding of themselves and their obligations, but with uncertainty as to how to translate or operationalize this in the context of a pandemic. This paper explores the "duty of care" from a legal perspective, distinguishes it from broader notions of duty on professional and personal levels, and proposes a working taxonomy for practitioners to better understand the concept of "duty" in their response to COVID-19.

General practitioners and decision-making capacity assessment: the experiences and educational needs of New Zealand general practitioners

BACKGROUND

Assessing decision-making capacity to health care is within the scope of practice for all doctors, yet the experience of GPs in this area is unknown.

OBJECTIVE

To explore the experiences, perspectives, approaches and challenges for GPs in New Zealand when conducting decision-making capacity assessments.

METHODS

Qualitative study design comprising individual in-depth semi-structured interviews conducted with a convenience sample of GPs. Interview transcripts were transcribed verbatim and analysed using a thematic analysis approach.

RESULTS

Twelve participants were recruited. The following themes emerged: (i) GPs' roles and responsibilities in decision-making capacity assessments; (ii) GPs lack formal training, knowledge, and confidence in decision-making capacity assessments; (iii) the legal interface of decision-making capacity assessments; (iv) GPs' relationships with specialists and the resulting impact on their confidence in decision-making capacity assessments; and (v) opportunities to improve GPs' knowledge and confidence in decision-making capacity assessments.

CONCLUSIONS

GPs take responsibility for decision-making capacity assessments; however, assessments can be complex. There is a need to develop specific curriculum and training resources for GPs to improve their clinical skills and legal knowledge in decision-making capacity assessments.

Voluntary assisted dying in Victoria: Why knowing the law matters to nurses

In 2017, Victoria became the first state in Australia to pass legislation permitting voluntary assisted dying. Under this law, only those people who are near the end of their lives may access voluntary assisted dying, and because many of these people require nursing care to manage the progression of their illness or their symptoms, it will invariably have an impact on nursing practice. The Victorian law includes a series of procedural steps as safeguards to ensure that the law operates as intended. To support people who choose voluntary assisted dying and to practice safely within boundaries of the law, nurses must be aware of these requirements and how they operate. However, there are often gaps in nurses' legal knowledge. This was demonstrated in an article that aimed to inform nurses about the operation of Voluntary Assisted Dying Act 2017 (Vic) but contained several errors and misstatements of the law. Our article corrects these errors and discusses how the law is intended to be applied by revisiting the fictional case of Chloe - a woman with a terminal illness who is seeking voluntary assisted dying. As the Voluntary Assisted Dying Act 2017 (Vic) also protects nurses from liability if they act in accordance with its provisions, we conclude that sound knowledge and understanding of its operation support nurses to provide the safe, comprehensive and compassionate care their patients deserve at the end of life.

The misuse of "duty of care" as justification for non-consensual coercive treatment

The duty of care concept is a common law legal principle which underpins all healthcare interactions. However, evidence within the Australian context suggests misuse of this common law principle as a justification for non-consensual coercive treatment. Misuse seems to occur particularly where patients have impaired decision-making capacity and/or refuse treatment. In this article, we discuss the emerging evidence of misuse, which arguably reflects healthcare practitioner confusion between the doctrines of 'duty of care' and 'necessity', and posit that cognisance of lawful substitute consent processes are lacking. We then discuss the concept of duty of care as an obligation, as opposed to a power, before presenting the elements of a valid consent and legislation relating to substitute consent, which allow health practitioners to proceed with treatment. We conclude this article with a discussion of the circumstances where treatment may be given without consent.

Overview of the Assisted Decision-Making (Capacity) Act (2015)

Purpose

In Ireland, the Assisted Decision Making (Capacity) Act 2015 provides a statutory framework to adults who are experiencing difficulties with decision-making. This legislation has significant implications for all who work in health and social care. Increasing age and life expectancy, alongside the rising incidence of chronic health conditions and dementia-related diseases, indicates that more individuals are likely to experience challenges regarding decision-making capacity. Therefore, the need for more consistent, best-practice processes to assess decision-making capacity is likely to increase. To ensure occupational therapists are responsible in their contributions, and to ensure those with disabilities are supported, clinicians must be well-informed of the principles underscoring the Act. The purpose of this paper is to provide an overview of this multidisciplinary issue, including recent legislation, and consider how occupational therapy can contribute.

Design/methodology/approach

The authors reviewed current literature and considered occupational therapy’s role in decision-making capacity assessment.

Findings

Occupational therapists have potential to play a key role in multi-disciplinary assessments of decision-making capacity for clients. Further research is required to explore professional issues, identify clinical best practices and determine training and resource needs.

Originality/value

This paper seeks to provoke consideration of how occupational therapists can contribute to capacity assessment from a client-centred, occupation-based perspective that is mindful of ethical and legislative considerations.

Staff awareness of the application of Mental Health and Guardianship Legislation in the care of hospitalised older persons

OBJECTIVE

The study aimed to survey hospital staff knowledge of the application of the Mental Health Act 2007 (NSW) (MHA) and the Guardianship Act 1987 (NSW) (GA) in the care and treatment of older persons in a teaching hospital in Sydney. Method Over a two-month period in 2017, a survey questionnaire was distributed to staff involved in older persons' care across the hospital.

RESULTS

The majority of the hospital staff demonstrated basic theoretical knowledge of both the GA (76%) and of the MHA (84.5%). Fewer (64.5%) appeared to understand the practical application of the MHA in the hypothetical clinical situations. An even lower proportion of staff appeared to understand the application of the GA either to obtain consent for medical treatment or to appoint a guardian through the Guardianship Division of the NSW Civil and Administrative Tribunal (NCAT).

CONCLUSION

Although clinical staff of the hospital displayed fair knowledge and awareness about the application of the MHA and the GA to inpatient care of older adults, further education is necessary, particularly about the application of the GA. The authors suggest similar findings may occur at other New South Wales hospitals, which may raise concern and need for education.

Medical Decision-Making Capacity

Abstract. Decision-making capacity (DMC) is a prerequisite for informed consent to medical treatments. However, little is known about the knowledge, attitudes, and evaluation of DMC among physicians in Croatia. A survey was conducted among 180 general practitioners and psychiatrists in Croatia. Although from a legal perspective DMC is a dichotomous concept, about 90% of physicians indicated that they understand DMC to be a gradual concept. A majority of physicians considered themselves responsible and qualified to conduct DMC evaluations, though some physicians considered themselves insufficiently qualified. General practitioners considered themselves less responsible and less qualified than psychiatrists. Almost all participants indicated that they would welcome official guidelines and training.